Planning
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Question 1 of 5.
The nurse is preparing a plan of care for a child diagnosed with leukemia who is beginning chemotherapy. Which intervention should the nurse include?
A. Monitor rectal temperatures every 4 hours.
B. Monitor the mouth and anus each shift for signs of breakdown.
C. Encourage the child to consume fresh fruits and vegetables to maintain nutritional status.
D. Provide meticulous mouth care several times daily using an alcohol-based mouthwash and a toothbrush.
Explanation: When the child is receiving chemotherapy, the nurse should assess the mouth and anus each shift for ulcers, erythema, or breakdown. The nurse should avoid taking rectal temperatures. Oral temperatures are also avoided if mouth ulcers are present. Axillary or temporal temperatures should be taken to prevent alterations in skin integrity. Bland, nonirritating foods and liquids should be provided to the child. Fresh fruits and vegetables need to be avoided because they can harbor organisms. Chemotherapy can cause neutropenia, and the child should be maintained on a low-bacteria diet if the white blood cell count is low. Meticulous mouth care should be performed, but the nurse should avoid alcohol-based mouthwashes and should use a soft-bristled toothbrush.
Question 2 of 5.
The nurse is caring for a client who is receiving total parenteral nutrition through a central venous catheter. Which action should the nurse plan to implement to decrease the risk of infection in this client?
A. Track the client's oral temperature.
B. Administer antibiotics intravenously.
C. Evaluate the differential of the leukocytes.
D. Use sterile technique for dressing changes.
Explanation: Sterile technique is vital during dressing changes of a central venous catheter (CVC). CVCs are large-bore catheters that can serve as a direct-entry point for microorganisms into the heart and circulatory system. Using aseptic technique helps avoid catheter-related infections by preventing the introduction of potential pathogens to the site. Although the remaining options are reasonable nursing interventions for a client with a CVC, none of them prevents infection. Options 1 and 3 are assessment methods, and option 2 is implemented after the confirmation of an existing infection.
Question 3 of 5.
The nurse creates a plan of care for a client with a spica cast that covers a lower extremity. Which action should the nurse include in the plan of care to promote bowel elimination?
A. Use a bedside commode.
B. Ambulate to the bathroom.
C. Administer an enema daily.
D. Use a low-profile (fracture) bedpan.
Explanation: A client with a spica cast (body cast) that covers a lower extremity cannot bend at the hips to sit up. A low-profile bedpan or fracture pan is designed for use by clients with body or leg casts and for clients who have difficulty raising the hips to use a standard bedpan; therefore, using a commode or the bathroom is contraindicated. Daily enemas are not a part of routine care.
Question 4 of 5.
The nurse is caring for a postpartum client with thromboembolytic disease. Which intervention is most important to include when planning care to prevent the complication of pulmonary embolism?
A. Enforce bed rest.
B. Monitor the vital signs frequently.
C. Assess the breath sounds frequently.
D. Administer prescribed anticoagulant therapy.
Explanation: The purposes of anticoagulant therapy for the treatment of thromboembolytic disease are to prevent the formation of a clot and to prevent a clot from moving to another area, thus preventing pulmonary embolism. Although the remaining options may be implemented for a client with thromboembolytic disease, the correct option will specifically assist in the prevention of pulmonary embolism.
Question 5 of 5.
The student nurse is listening to a lecture on serum electrolyte levels and the use of isotonic solutions. Which statement by the student nurse indicates that the teaching has been effective?
A. 10% dextrose in water is a hypotonic solution.
B. 3% sodium chloride solution is a hypotonic solution.
C. 5% dextrose in water is considered an isotonic solution.
D. 0.45% sodium chloride solution is a hypertonic solution.
Explanation: Five percent dextrose in water is an isotonic solution, which means that the osmolality of this solution matches normal body fluids. Other examples of isotonic fluids include 0.9% sodium chloride solution (normal saline) and lactated Ringer's solution. Ten percent dextrose in water and 3% sodium chloride solution are hypertonic solutions, and 0.45% sodium chloride solution is hypotonic.
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